The Reducing Opioid Use in Children with Clefts Protocol: A Multidisciplinary Quality Improvement Effort to Reduce Perioperative Opioid Use in Patients Undergoing Cleft Surgery

Abstract

Background: Cleft repair requires multiple operations from infancy through adolescence, with repeated exposure to opioids and their associated risks. The authors implemented a quality improvement project to reduce perioperative opioid exposure in their cleft lip/palate population. Methods: After identifying key drivers of perioperative opioid administration, quality improvement interventions were developed to address these key drivers and reduce postoperative opioid administration from 0.30 mg/kg of morphine equivalents to 0.20 mg/kg of morphine equivalents. Data were retrospectively collected from January 1, 2015, until initiation of the quality improvement project (May 1, 2017), tracked over the 6-month quality improvement study period, and the subsequent 14 months. Metrics included morphine equivalents of opioids received during admission, administration of intraoperative nerve blocks, adherence to revised electronic medical record order sets, length of stay, and pain scores. Results: The final sample included 624 patients. Before implementation (n =354), children received an average of 0.30 mg/kg of morphine equivalents postoperatively. After implementation (n = 270), children received an average of 0.14 mg/kg of morphine equivalents postoperatively (p < 0.001) without increased length of stay (28.3 versus 28.7 hours; p = 0.719) or pain at less than 6 hours (1.78 versus 1.74; p = 0.626) or more than 6 hours postoperatively (1.50 versus 1.49; p = 0.924). Conclusions: Perioperative opioid administration after cleft repair can be reduced in a relatively short period by identifying key drivers and addressing perioperative education, standardization of intraoperative pain control, and postoperative prioritization of nonopioid medications and nonpharmacologic pain control. The authors’ quality improvement framework has promise for adaptation in future efforts to reduce opioid use in other surgical patient populations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Perioperative Pain Management in Cleft Lip and Palate Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Studies

“…3,4 Thus, developing effective strategies to manage perioperative pain, a key component of such protocols, remains a focus of cleft care. 5…”

Opioid Prescribing Practices in Cleft Lip and Cleft Palate Reconstruction

“…Lee and colleagues advocated for decreasing morphine use after pediatric cleft surgery by strict adherence to a standardized order set and administration of intraoperative nerve blocks. The intervention group required significantly less oral morphine equivalents on average compared to controls (0.14 vs 0.30 mg/kg; P < .001) without a significant change in length of stay or pain scores (Lee et al, 2020).…”

“…Multimodal therapies have been used to successfully decrease opioid use in pediatric patients after cleft surgeries, ideally allowing patients to be more awake with better airway control postoperatively. Important components of opioid reduction initiatives include provider and patient education, the utilization of nonopioid medications and nonpharmacologic pain control methods, and the standardization of a pain control protocol (Lee et al, 2020). Lee and colleagues advocated for decreasing morphine use after pediatric cleft surgery by strict adherence to a standardized order set and administration of intraoperative nerve blocks.…”

“…Strategies for perioperative pain management that can minimize opioid use are integral to decreasing narcotic-related morbidity in cleft surgery. Such methods may employ multimodal techniques, including nonsteroidal anti-inflammatory drug (NSAID) medications, and intraoperative nerve blocks, both of which have been shown to decrease opioid usage after pediatric cleft surgeries (Mesnil et al, 2010;Nour et al, 2014;Lee et al, 2020). Currently, there are limited guidelines and no professional consensus on the use of opioids and adjunct therapies in the management of perioperative pain in children undergoing cleft surgery (Lasky et al, 2012).…”

Optimizing Outcomes After Cleft Palate Repair: Design and Implementation of a Perioperative Clinical Care Pathway

“…Recent work has demonstrated that regional anesthesia via ultrasound-guided maxillary nerve blockade reduces cumulative opiate consumption over the first 48 hours postoperatively (Mesnil et al, 2010; Chiono et al, 2014). Attempts to standardize postoperative care for patients with clefts have also been associated with reduced postoperative opioid consumption (Lee et al, 2020; Moffitt et al, 2021). Despite these findings, significant variability in analgesic approach continues to exist among pediatric centers.…”